Provider Demographics
NPI:1235378019
Name:DAVIDSEN, DAN CARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:CARL
Last Name:DAVIDSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29W150 BUTTERFIELD RD.
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555
Mailing Address - Country:US
Mailing Address - Phone:630-393-2120
Mailing Address - Fax:
Practice Address - Street 1:29W150 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-2804
Practice Address - Country:US
Practice Address - Phone:630-393-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-01973-91223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice